Provider Demographics
NPI:1215514658
Name:WILLIAMSON, JEFFREY LEE (CMT)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LEE
Last Name:WILLIAMSON
Suffix:
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:JEFFREY
Other - Middle Name:LEE
Other - Last Name:WILLIAMSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:JEFF
Mailing Address - Street 1:3945 GEORGIA ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-3504
Mailing Address - Country:US
Mailing Address - Phone:619-372-6869
Mailing Address - Fax:
Practice Address - Street 1:3945 GEORGIA ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-3504
Practice Address - Country:US
Practice Address - Phone:619-372-6869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48601225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist